Routine inspection·May 28, 2021

On 05/28/2021 at 9:35am, Licensing Program Analyst (LPA) T. White spoke with Licensee, Sherwan Matammu regarding facility risk assessment questions. Licensee confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:50am, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Administrator, Priscilla Quipevis and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 24 non-ambulatory residents, which 6 may be on hospice. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111 and 109 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. LPA observed smoke detectors is interconnected with the fire department. Fire extinguisher was last serviced on January 23, 2021. Administrator stated she is waiting on guidance from referral agency for the mitigation plan corrections. - LPA observed carbon monoxide was not in operating condition during inspection. - LPA observed front door with tape around the door knob. LPA observed front door in disrepair. - LPA observed a emergency door in disrepair. - LPA observed two staff members not properly wearing masks. - LPA observed residents shared bedroom blinds were not in good condition. Report continues on 809C. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/11/2021: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610 Emergency Disaster Plan The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted with Administrator. A copy of report and appeal rights given.